Basic Information
| Provider Information | |||||||||
| NPI: | 1811419708 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACK CANYON MEDICAL GROUP PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 426 HIGHWAY 16 | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836179461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083652735 | ||||||||
| FaxNumber: | 2083652737 | ||||||||
| Practice Location | |||||||||
| Address1: | 426 HIGHWAY 16 | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836179461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083652735 | ||||||||
| FaxNumber: | 2083652737 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCGUFFEY | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2083652735 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M9309 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1346654589 | 05 | ID | MEDICAID | 1306873435 | 05 | ID | MEDICAID |